World Professional Association for Transgender Health, (formerly The Harry Benjamin International Gender Dysphoria Association) Standards of Care
Ami B. Kaplan, LCSW,
Licensed Psychotherapist
113 University Place #1008, New York, NY 10003 (212) 358-1884 info@amikaplan.netPsychotherapy and Psychoanalysis
The following are the 'WPATH"
The Harry Benjamin International Gender Dysphoria Association's
Standards Of Care For Gender Identity Disorders, Sixth Version
February, 2001
This is the sixth version of the Standards of Care since the original 1979 document.
Previous revisions were in 1980, 1981, 1990, and 1998.
Table of Contents:
I. Introductory Concepts
II. Epidemiological Considerations
III. Diagnostic Nomenclature
IV. The Mental Health Professional
V. Assessment and Treatment of Children and Adolescents
VI. Psychotherapy with Adults
VII. Requirements for Hormone Therapy for Adults
VIII. Effects of Hormone Therapy in Adults
IX. The Real-life Experience
X. Surgery
XI. Breast Surgery
XII. Genital Surgery
XIII. Post-Transition Follow-up
I. Introductory Concepts
The Purpose of the Standards of Care. The major purpose of the Standards of Care (SOC) is to
articulate this international organization's professional consensus about the psychiatric,
psychological, medical, and surgical management of gender identity disorders. Professionals
may use this document to understand the parameters within which they may offer assistance to
those with these conditions. Persons with gender identity disorders, their families, and social
institutions may use the SOC to understand the current thinking of professionals. All readers
should be aware of the limitations of knowledge in this area and of the hope that some of the
clinical uncertainties will be resolved in the future through scientific investigation.
The Overarching Treatment Goal. The general goal of psychotherapeutic, endocrine, or
surgical therapy for persons with gender identity disorders is lasting personal comfort with the
gendered self in order to maximize overall psychological well-being and self-fulfillment.
The Standards of Care Are Clinical Guidelines. The SOC are intended to provide flexible
directions for the treatment of persons with gender identity disorders. When eligibility
requirements are stated they are meant to be minimum requirements. Individual professionals
and organized programs may modify them. Clinical departures from these guidelines may come
about because of a patient's unique anatomic, social, or psychological situation, an experienced
professional’s evolving method of handling a common situation, or a research protocol. These
departures should be recognized as such, explained to the patient, and documented both for legal
protection and so that the short and long term results can be retrieved to help the field to evolve.
The Clinical Threshold. A clinical threshold is passed when concerns, uncertainties, and
questions about gender identity persist during a person’s development, become so intense as to
seem to be the most important aspect of a person's life, or prevent the establishment of a
relatively unconflicted gender identity. The person's struggles are then variously informally
referred to as a gender identity problem, gender dysphoria, a gender problem, a gender concern,
gender distress, gender conflict, or transsexualism. Such struggles are known to occur from the
preschool years to old age and have many alternate forms. These reflect various degrees of
personal dissatisfaction with sexual identity, sex and gender demarcating body characteristics,
gender roles, gender identity, and the perceptions of others. When dissatisfied individuals meet
specified criteria in one of two official nomenclatures--the International Classification of
Diseases-10 (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders--Fourth
Edition (DSM-IV)--they are formally designated as suffering from a gender identity disorder
(GID). Some persons with GID exceed another threshold--they persistently possess a wish for
surgical transformation of their bodies.
Two Primary Populations with GID Exist -- Biological Males and Biological Females. The
sex of a patient always is a significant factor in the management of GID. Clinicians need to
separately consider the biologic, social, psychological, and economic dilemmas of each sex. All
patients, however, should follow the SOC.
II. Epidemiological Considerations
Prevalence. When the gender identity disorders first came to professional attention, clinical
perspectives were largely focused on how to identify candidates for sex reassignment surgery. As
the field matured, professionals recognized that some persons with bona fide gender identity
disorders neither desired nor were candidates for sex reassignment surgery. The earliest
estimates of prevalence for transsexualism in adults were 1 in 37,000 males and 1 in 107,000
females. The most recent prevalence information from the Netherlands for the transsexual end of
the gender identity disorder spectrum is 1 in 11,900 males and 1 in 30,400 females. Four
observations, not yet firmly supported by systematic study, increase the likelihood of an even
higher prevalence: 1) unrecognized gender problems are occasionally diagnosed when patients
are seen with anxiety, depression, bipolar disorder, conduct disorder, substance abuse,
dissociative identity disorders, borderline personality disorder, other sexual disorders and
intersexed conditions; 2) some nonpatient male transvestites, female impersonators, transgender
people, and male and female homosexuals may have a form of gender identity disorder; 3) the
intensity of some persons' gender identity disorders fluctuates below and above a clinical
threshold; 4) gender variance among female-bodied individuals tends to be relatively invisible to
the culture, particularly to mental health professionals and scientists.
Natural History of Gender Identity Disorders. Ideally, prospective data about the natural
history of gender identity struggles would inform all treatment decisions. These are lacking,
except for the demonstration that, without therapy, most boys and girls with gender identity
disorders outgrow their wish to change sex and gender. After the diagnosis of GID is made the
therapeutic approach usually includes three elements or phases (sometimes labeled triadic
therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery
to change the genitalia and other sex characteristics. Five less firmly scientifically established
observations prevent clinicians from prescribing the triadic therapy based on diagnosis alone: 1)
some carefully diagnosed persons spontaneously change their aspirations; 2) others make more
comfortable accommodations to their gender identities without medical interventions; 3) others
give up their wish to follow the triadic sequence during psychotherapy; 4) some gender identity
clinics have an unexplained high drop out rate; and 5) the percentage of persons who are not
benefited from the triadic therapy varies significantly from study to study. Many persons with
GID will desire all three elements of triadic therapy. Typically, triadic therapy takes place in the
order of hormones = = > real-life experience = = > surgery, or sometimes: real-life experience =
= > hormones = = > surgery. For some biologic females, the preferred sequence may be
hormones = = > breast surgery = = > real-life experience. However, the diagnosis of GID invites
the consideration of a variety of therapeutic options, only one of which is the complete
therapeutic triad. Clinicians have increasingly become aware that not all persons with gender
identity disorders need or want all three elements of triadic therapy.
Cultural Differences in Gender Identity Variance throughout the World. Even if
epidemiological studies established that a similar base rate of gender identity disorders existed
all over the world, it is likely that cultural differences from one country to another would alter
the behavioral expressions of these conditions. Moreover, access to treatment, cost of treatment,
the therapies offered and the social attitudes towards gender variant people and the professionals
who deliver care differ broadly from place to place. While in most countries, crossing gender
boundaries usually generates moral censure rather than compassion, there are striking examples
in certain cultures of cross-gendered behaviors (e.g., in spiritual leaders) that are not stigmatized.
III. Diagnostic Nomenclature
The Five Elements of Clinical Work. Professional involvement with patients with gender
identity disorders involves any of the following: diagnostic assessment, psychotherapy, real-life
experience, hormone therapy, and surgical therapy. This section provides a background on
diagnostic assessment.
The Development of a Nomenclature. The term transexxual emerged into professional and
public usage in the 1950s as a means of designating a person who aspired to or actually lived in
the anatomically contrary gender role, whether or not hormones had been administered or
surgery had been performed. During the 1960s and 1970s, clinicians used the term true
transsexual. The true transsexual was thought to be a person with a characteristic path of atypical
gender identity development that predicted an improved life from a treatment sequence that
culminated in genital surgery. True transsexuals were thought to have:1) cross-gender
identifications that were consistently expressed behaviorally in childhood, adolescence, and
adulthood;2) minimal or no sexual arousal to cross-dressing; and
3) no heterosexual interest,
relative to their anatomic sex.True transsexuals could be of either sex. True transsexual males
were distinguished from males who arrived at the desire to change sex and gender via a
reasonably masculine behavioral developmental pathway. Belief in the true transsexual concept
for males dissipated when it was realized that such patients were rarely encountered, and
thatsome of the original true transsexuals had falsified their histories to make their stories match
the earliest theories about the disorder. The concept of true transsexual females never created
diagnostic uncertainties, largely because patient histories were relatively consistent and gender
variant behaviors such as female cross-dressing remained unseen by clinicians. The term "gender
dysphoria syndrome" was later adopted to designate the presence of a gender problem in either
sex until psychiatry developed an official nomenclature.
The diagnosis of Transsexualism was introduced in the DSM-III in 1980 for gender dysphoric
individuals who demonstrated at least two years of continuous interest in transforming the sex of
their bodies and their social gender status. Others with gender dysphoria could be diagnosed as
Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type; or Gender
Identity Disorder Not Otherwise Specified (GIDNOS). These diagnostic terms were usually
ignored by the media, which used the term transsexual for any person who wanted to change
his/her sex and gender.
The DSM-IV. In 1994, the DSM-IV committee replaced the diagnosis of Transsexualism with
Gender Identity Disorder. Depending on their age, those with a strong and persistent crossgender
identification and a persistent discomfort with their sex or a sense of inappropriateness in
the gender role of that sex were to be diagnosed as Gender Identity Disorder of Childhood
(302.6), Adolescence, or Adulthood (302.85). For persons who did not meet these criteria,
Gender Identity Disorder Not Otherwise Specified (GIDNOS)(302.6) was to be used. This
category included a variety of individuals, including those who desired only castration or
penectomy without a desire to develop breasts, those who wished hormone therapy and
mastectomy without genital reconstruction, those with a congenital intersex condition, those with
transient stress-related cross-dressing, and those with considerable ambivalence about giving up
their gender status. Patients diagnosed with GID and GIDNOS were to be subclassified
according to the sexual orientation: attracted to males; attracted to females; attracted to both; or
attracted to neither. This subclassification was intended to assist in determining, over time,
whether individuals of one sexual orientation or another experienced better outcomes using
particular therapeutic approaches; it was not intended to guide treatment decisions.
Between the publication of DSM-III and DSM-IV, the term "transgender" began to be used in
various ways. Some employed it to refer to those with unusual gender identities in a value-free
manner -- that is, without a connotation of psychopathology. Some people informally used the
term to refer to any person with any type of gender identity issues. Transgender is not a formal
diagnosis, but many professionals and members of the public found it easier to use informally
than GIDNOS, which is a formal diagnosis.
The ICD-10. The ICD-10 now provides five diagnoses for the gender identity disorders (F64):
Transsexualism (F64.0) has three criteria:
1. The desire to live and be accepted as a member of the opposite sex, usually accompanied
by the wish to make his or her body as congruent as possible with the preferred sex through
surgery and hormone treatment;
2. The transsexual identity has been present persistently for at least two years;
3. The disorder is not a symptom of another mental disorder or a chromosomal abnormality.
Dual-role Transvestism (F64.1) has three criteria:
1. The individual wears clothes of the opposite sex in order to experience temporary
membership in the opposite sex;
2. There is no sexual motivation for the cross-dressing;
3. The individual has no desire for a permanent change to the opposite sex.\
Gender Identity Disorder of Childhood (64.2) has separate criteria for girls and for boys.
For girls:
1. The individual shows persistent and intense distress about being a girl, and has a stated
desire to be a boy (not merely a desire for any perceived cultural advantages to being a
boy) or insists that she is a boy;
2. Either of the following must be present:
a. Persistent marked aversion to normative feminine clothing and insistence on
wearing stereotypical masculine clothing;
b. Persistent repudiation of female anatomical structures, as evidenced by at least one
of the following:
1. An assertion that she has, or will grow, a penis;
2. Rejection of urination in a sitting position;
3. Assertion that she does not want to grow breasts or menstruate.
3. The girl has not yet reached puberty;
4. The disorder must have been present for at least 6 months.
For boys:
1. The individual shows persistent and intense distress about being a boy, and has a desire
to be a girl, or, more rarely, insists that he is a girl.
2. Either of the following must be present:
a. Preoccupation with stereotypic female activities, as shown by a preference for
either cross-dressing or simulating female attire, or by an intense desire to
participate in the games and pastimes of girls and rejection of stereotypical male
toys, games, and activities;
b. Persistent repudiation of male anatomical structures, as evidenced by at least one of
the following repeated assertions:
1. That he will grow up to become a woman (not merely in the role);
2. That his penis or testes are disgusting or will disappear;
3. That it would be better not to have a penis or testes.
3. The boy has not yet reached puberty;
4. The disorder must have been present for at least 6 months.
Other Gender Identity Disorders (F64.8) has no specific criteria.
Gender Identity Disorder, Unspecified has no specific criteria.
6
Either of the previous two diagnoses could be used for those with an intersexed condition.
The purpose of the DSM-IV and ICD-10 is to guide treatment and research. Different
professional groups created these nomenclatures through consensus processes at different times.
There is an expectation that the differences between the systems will be eliminated in the future.
At this point, the specific diagnoses are based more on clinical reasoning than on scientific
investigation.
Are Gender Identity Disorders Mental Disorders? To qualify as a mental disorder, a
behavioral pattern must result in a significant adaptive disadvantage to the person or cause
personal mental suffering. The DSM-IV and ICD-10 have defined hundreds of mental disorders
which vary in onset, duration, pathogenesis, functional disability, and treatability. The
designation of gender identity disorders as mental disorders is not a license for stigmatization, or
for the deprivation of gender patients' civil rights. The use of a formal diagnosis is often
important in offering relief, providing health insurance coverage, and guiding research to provide
more effective future treatments.
IV. The Mental Health Professional
The Ten Tasks of the Mental Health Professional. Mental health professionals (MHPs) who
work with individuals with gender identity disorders may be regularly called upon to carry out
many of these responsibilities:
1. To accurately diagnose the individual's gender disorder;
2. To accurately diagnose any co-morbid psychiatric conditions and see to their appropriate
treatment;
3. To counsel the individual about the range of treatment options and their implications;
4. To engage in psychotherapy;
5. To ascertain eligibility and readiness for hormone and surgical therapy;
6. To make formal recommendations to medical and surgical colleagues;
7. To document their patient's relevant history in a letter of recommendation;
8. To be a colleague on a team of professionals with an interest in the gender identity
disorders;
9. To educate family members, employers, and institutions about gender identity disorders;
10. To be available for follow-up of previously seen gender patients.
The Adult-Specialist. The education of the mental health professional who specializes in adult
gender identity disorders rests upon basic general clinical competence in diagnosis and treatment
of mental or emotional disorders. Clinical training may occur within any formally credentialing
discipline -- for example, psychology, psychiatry, social work, counseling, or nursing. The
following are the recommended minimal credentials for special competence with the gender
identity disorders:
1. A master's degree or its equivalent in a clinical behavioral science field. This or a more
advanced degree should be granted by an institution accredited by a recognized national
or regional accrediting board. The mental health professional should have documented
credentials from a proper training facility and a licensing board.
2. Specialized training and competence in the assessment of the DSM-IV/ICD-10 Sexual
Disorders (not simply gender identity disorders).
3. Documented supervised training and competence in psychotherapy.
4. Continuing education in the treatment of gender identity disorders, which may include
attendance at professional meetings, workshops, or seminars or participating in research
related to gender identity issues.
The Child-Specialist. The professional who evaluates and offers therapy for a child or early
adolescent with GID should have been trained in childhood and adolescent developmental
psychopathology. The professional should be competent in diagnosing and treating the ordinary
problems of children and adolescents. These requirements are in addition to the adult-specialist
requirement.
The Differences between Eligibility and Readiness. The SOC provide recommendations for
eligibility requirements for hormones and surgery. Without first meeting these recommended
eligibility requirements, the patient and the therapist should not request hormones or surgery. An
example of an eligibility requirement is: a person must live full time in the preferred gender for
twelve months prior to genital surgery. To meet this criterion, the professional needs to
document that the real-life experience has occurred for this duration. Meeting readiness criteria --
further consolidation of the evolving gender identity or improving mental health in the new or
confirmed gender role -- is more complicated, because it rests upon the clinician's and the
patient’s judgment.
The Mental Health Professional's Relationship to the Prescribing Physician and Surgeon.
Mental health professionals who recommend hormonal and surgical therapy share the legal and
ethical responsibility for that decision with the physician who undertakes the treatment.
Hormonal treatment can often alleviate anxiety and depression in people without the use of
additional psychotropic medications. Some individuals, however, need psychotropic medication
prior to, or concurrent with, taking hormones or having surgery. The mental health professional
is expected to make this assessment, and see that the appropriate psychotropic medications are
offered to the patient. The presence of psychiatric co-morbidities does not necessarily preclude
hormonal or surgical treatment, but some diagnoses pose difficult treatment dilemmas and may
delay or preclude the use of either treatment.
The Mental Health Professional’s Documentation Letter for Hormone Therapy or Surgery
Should Succinctly Specify:
1. The patient's general identifying characteristics;
2. The initial and evolving gender, sexual, and other psychiatric diagnoses;
3. The duration of their professional relationship including the type of psychotherapy or
evaluation that the patient underwent;
4. The eligibility criteria that have been met and the mental health professional’s rationale
for hormone therapy or surgery;
5. The degree to which the patient has followed the Standards of Care to date and the
likelihood of future compliance;
6. Whether the author of the report is part of a gender team;
8
7. That the sender welcomes a phone call to verify the fact that the mental health
professional actually wrote the letter as described in this document.
The organization and completeness of these letters provide the hormone-prescribing physician
and the surgeon an important degree of assurance that mental health professional is
knowledgeable and competent concerning gender identity disorders.
One Letter is Required for Instituting Hormone Therapy, or for Breast Surgery. One letter
from a mental health professional, including the above seven points, written to the physician who
will be responsible for the patient’s medical treatment, is sufficient for instituting hormone
therapy or for a referral for breast surgery (e.g., mastectomy, chest reconstruction, or
augmentation mammoplasty).
Two Letters are Generally Required for Genital Surgery. Genital surgery for biologic males
may include orchiectomy, penectomy, clitoroplasty, labiaplasty or creation of a neovagina; for
biologic females it may include hysterectomy, salpingo-oophorectomy, vaginectomy,
metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses, or creation of a
neophallus.
It is ideal if mental health professionals conduct their tasks and periodically report on these
processes as part of a team of other mental health professionals and nonpsychiatric physicians.
One letter to the physician performing genital surgery will generally suffice as long as two
mental health professionals sign it.
More commonly, however, letters of recommendation are from mental health professionals who
work alone without colleagues experienced with gender identity disorders. Because professionals
working independently may not have the benefit of ongoing professional consultation on gender
cases, two letters of recommendation are required prior to initiating genital surgery. If the first
letter is from a person with a master's degree, the second letter should be from a psychiatrist or a
Ph.D. clinical psychologist, who can be expected to adequately evaluate co-morbid psychiatric
conditions. If the first letter is from the patient's psychotherapist, the second letter should be from
a person who has only played an evaluative role for the patient. Each letter, however, is expected
to cover the same topics. At least one of the letters should be an extensive report. The second
letter writer, having read the first letter, may choose to offer a briefer summary and an agreement
with the recommendation.
V. Assessment and Treatment of Children and Adolescents
Phenomenology. Gender identity disorders in children and adolescents are different from those
seen in adults, in that a rapid and dramatic developmental process (physical, psychological and
sexual) is involved. Gender identity disorders in children and adolescents are complex
conditions. The young person may experience his or her phenotype sex as inconsistent with his
or her own sense of gender identity. Intense distress is often experienced, particularly in
adolescence, and there are frequently associated emotional and behavioral difficulties. There is
greater fluidity and variability in outcomes, especially in pre-pubertal children. Only a few
9
gender variant youths become transsexual, although many eventually develop a homosexual
orientation.
Physical interventions fall into three categories or stages:
1. Fully reversible interventions. These involve the use of LHRH agonists or
medroxyprogesterone to suppress estrogen or testosterone production, and
consequently
to delay the physical changes of puberty.
2. Partially reversible interventions. These include hormonal interventions
that masculinize
or feminize the body, such as administration of testosterone to biologic
females and
estrogen to biologic males. Reversal may involve surgical intervention.
3. Irreversible interventions. These are surgical procedures.
A staged process is recommended to keep options open through the first two
stages. Moving
from one state to another should not occur until there has been adequate
time for the young
person and his/her family to assimilate fully the effects of earlier
interventions.
Fully Reversible Interventions. Adolescents may be eligible for
puberty-delaying hormones as
soon as pubertal changes have begun. In order for the adolescent and his or
her parents to make
an informed decision about pubertal delay, it is recommended that the
adolescent experience the
onset of puberty in his or her biologic sex, at least to Tanner Stage Two.
If for clinical reasons it
is thought to be in the patient’s interest to intervene earlier, this must
be managed with pediatric
endocrinological advice and more than one psychiatric opinion.
Two goals justify this intervention: a) to gain time to further explore the
gender identity and
other developmental issues in psychotherapy; and b) to make passing easier
if the adolescent
continues to pursue sex and gender change. In order to provide puberty
delaying hormones to an
adolescent, the following criteria must be met:
1. throughout childhood the adolescent has demonstrated an intense pattern
of cross-sex and
cross-gender identity and aversion to expected gender role behaviors;
2. sex and gender discomfort has significantly increased with the onset of
puberty;
3. the family consents and participates in the therapy.
Biologic males should be treated with LHRH agonists (which stop LH secretion
and therefore
testosterone secretion), or with progestins or antiandrogens (which block
testosterone secretion
or neutralize testosterone action). Biologic females should be treated with
LHRH agonists or
with sufficient progestins (which stop the production of estrogens and
progesterone) to stop
menstruation.
Partially Reversible Interventions. Adolescents may be eligible to begin
masculinizing or
feminizing hormone therapy as early as age 16, preferably with parental
consent. In many
countries 16-year olds are legal adults for medical decision making, and do
not require parental
consent.
Mental health professional involvement is an eligibility requirement for
triadic therapy during
adolescence. For the implementation of the real-life experience or hormone
therapy, the mental
health professional should be involved with the patient and family for a
minimum of six months.
While the number of sessions during this six-month period rests upon the
clinician’s judgment,
the intent is that hormones and the real-life experience be thoughtfully and
recurrently
considered over time. In those patients who have already begun the real-life
experience prior to
being seen, the professional should work closely with them and their
families with the thoughtful
recurrent consideration of what is happening over time.
Irreversible Interventions. Any surgical intervention should not be carried
out prior to
adulthood, or prior to a real-life experience of at least two years in the
gender role of the sex with
which the adolescent identifies. The threshold of 18 should be seen as an
eligibility criterion and
not an indication in itself for active intervention.
VI. Psychotherapy with Adults
A Basic Observation. Many adults with gender identity disorder find
comfortable, effective
ways of living that do not involve all the components of the triadic
treatment sequence. While
some individuals manage to do this on their own, psychotherapy can be very
helpful in bringing
about the discovery and maturational processes that enable self-comfort.
Psychotherapy is Not an Absolute Requirement for Triadic Therapy. Not every
adult gender
patient requires psychotherapy in order to proceed with hormone therapy, the
real-life
experience, hormones, or surgery. Individual programs vary to the extent
that they perceive a
need for psychotherapy. When the mental health professional's initial
assessment leads to a
recommendation for psychotherapy, the clinician should specify the goals of
treatment, and
estimate its frequency and duration. There is no required minimum number of
psychotherapy
sessions prior to hormone therapy, the real-life experience, or surgery, for
three reasons: 1)
patients differ widely in their abilities to attain similar goals in a
specified time; 2) a minimum
number of sessions tends to be construed as a hurdle, which discourages the
genuine opportunity
for personal growth; 3) the mental health professional can be an important
support to the patient
throughout all phases of gender transition. Individual programs may set
eligibility criteria to
some minimum number of sessions or months of psychotherapy.
The mental health professional who conducts the initial evaluation need not
be the
psychotherapist. If members of a gender team do not do psychotherapy, the
psychotherapist
should be informed that a letter describing the patient's therapy might be
requested so the patient
can proceed with the next phase of treatment.
Goals of Psychotherapy. Psychotherapy often provides education about a range
of options not
previously seriously considered by the patient. It emphasizes the need to
set realistic life goals
for work and relationships, and it seeks to define and alleviate the
patient's conflicts that may
have undermined a stable lifestyle.
The Therapeutic Relationship. The establishment of a reliable trusting
relationship with the
patient is the first step toward successful work as a mental health
professional. This is usually
accomplished by competent nonjudgmental exploration of the gender issues
with the patient
during the initial diagnostic evaluation. Other issues may be better dealt
with later, after the
person feels that the clinician is interested in and understands their
gender identity concerns.
Ideally, the clinician's work is with the whole of the person's complexity.
The goals of therapy
are to help the person to live more comfortably within a gender identity and
to deal effectively
with non-gender issues. The clinician often attempts to facilitate the
capacity to work and to
establish or maintain supportive relationships. Even when these initial
goals are attained, mental
health professionals should discuss the likelihood that no educational,
psychotherapeutic,
medical, or surgical therapy can permanently eradicate all vestiges of the
person's original sex
assignment and previous gendered experience.
Processes of Psychotherapy. Psychotherapy is a series of interactive
communications between a
therapist who is knowledgeable about how people suffer emotionally and how
this may be
alleviated, and a patient who is experiencing distress. Typically,
psychotherapy consists of
regularly held 50-minutes sessions. The psychotherapy sessions initiate a
developmental process.
They enable the patient’s history to be appreciated, current dilemmas to be
understood, and
unrealistic ideas and maladaptive behaviors to be identified. Psychotherapy
is not intended to
cure the gender identity disorder. Its usual goal is a long-term stable life
style with realistic
chances for success in relationships, education, work, and gender identity
expression. Gender
distress often intensifies relationship, work, and educational dilemmas.
The therapist should make clear that it is the patient's right to choose
among many options. The
patient can experiment over time with alternative approaches. Ideally,
psychotherapy is a
collaborative effort. The therapist must be certain that the patient
understands the concepts of
eligibility and readiness, because the therapist and patient must cooperate
in defining the
patient's problems, and in assessing progress in dealing with them.
Collaboration can prevent a
stalemate between a therapist who seems needlessly withholding of a
recommendation, and a
patient who seems too profoundly distrusting to freely share thoughts,
feelings, events, and
relationships.
Patients may benefit from psychotherapy at every stage of gender evolution.
This includes the
post-surgical period, when the anatomic obstacles to gender comfort have
been removed, but the
person may continue to feel a lack of genuine comfort and skill in living in
the new gender role.
Options for Gender Adaptation. The activities and processes that are listed
below have, in
various combinations, helped people to find more personal comfort. These
adaptations may
evolve spontaneously and during psychotherapy. Finding new gender
adaptations does not mean
that the person may not in the future elect to pursue hormone therapy, the
real-life experience, or
genital surgery.
Activities:
Biological Males:
1. Cross-dressing: unobtrusively with undergarments; unisexually; or in a
feminine fashion;
2. Changing the body through: hair removal through electrolysis or body
waxing; minor
plastic cosmetic surgical procedures;
3. Increasing grooming, wardrobe, and vocal expression skills.
Biological Females:
1. Cross-dressing: unobtrusively with undergarments, unisexually, or in a
masculine
fashion;
2. Changing the body through breast binding, weight lifting, applying
theatrical facial hair;
3. Padding underpants or wearing a penile prosthesis.
Both Genders:
1. Learning about transgender phenomena from: support groups and gender
networks,
communication with peers via the Internet, studying these Standards of Care,
relevant lay
and professional literatures about legal rights pertaining to work,
relationships, and public
cross-dressing;
2. Involvement in recreational activities of the desired gender;
3. Episodic cross-gender living.
Processes:
1. Acceptance of personal homosexual or bisexual fantasies and behaviors
(orientation) as
distinct from gender identity and gender role aspirations;
2. Acceptance of the need to maintain a job, provide for the emotional needs
of children,
honor a spousal commitment, or not to distress a family member as currently
having a
higher priority than the personal wish for constant cross-gender expression;
3. Integration of male and female gender awareness into daily living;
4. Identification of the triggers for increased cross-gender yearnings and
effectively
attending to them; for instance, developing better self-protective,
self-assertive, and
vocational skills to advance at work and resolve interpersonal struggles to
strengthen key
relationships.
VII. Requirements for Hormone Therapy for Adults
Reasons for Hormone Therapy. Cross-sex hormonal treatments play an important
role in the
anatomical and psychological gender transition process for properly selected
adults with gender
identity disorders. Hormones are often medically necessary for successful
living in the new
gender. They improve the quality of life and limit psychiatric co-morbidity,
which often
accompanies lack of treatment. When physicians administer androgens to
biologic females and
estrogens, progesterone, and testosterone-blocking agents to biologic males,
patients feel and
appear more like members of their preferred gender.
Eligibility Criteria. The administration of hormones is not to be lightly
undertaken because of
their medical and social risks. Three criteria exist.
1. Age 18 years;
2. Demonstrable knowledge of what hormones medically can and cannot do and
their social
benefits and risks;
3. Either:
a. A documented real-life experience of at least three months prior to the
administration
of hormones; or
b. A period of psychotherapy of a duration specified by the mental health
professional
after the initial evaluation (usually a minimum of three months).
In selected circumstances, it can be acceptable to provide hormones to
patients who have not
fulfilled criterion 3 – for example, to facilitate the provision of
monitored therapy using
hormones of known quality, as an alternative to black-market or unsupervised
hormone use.
Readiness Criteria. Three criteria exist:
1. The patient has had further consolidation of gender identity during the
real-life
experience or psychotherapy;
2. The patient has made some progress in mastering other identified problems
leading to
improving or continuing stable mental health (this implies satisfactory
control of
problems such as sociopathy, substance abuse, psychosis and suicidality;
3. The patient is likely to take hormones in a responsible manner.
Can Hormones Be Given To Those Who Do Not Want Surgery or a Real-life
Experience?
Yes, but after diagnosis and psychotherapy with a qualified mental health
professional following
minimal standards listed above. Hormone therapy can provide significant
comfort to gender
patients who do not wish to cross live or undergo surgery, or who are unable
to do so. In some
patients, hormone therapy alone may provide sufficient symptomatic relief to
obviate the need
for cross living or surgery.
Hormone Therapy and Medical Care for Incarcerated Persons. Persons who are
receiving
treatment for gender identity disorders should continue to receive
appropriate treatment
following these Standards of Care after incarceration. For example, those
who are receiving
psychotherapy and/or cross-sex hormonal treatments should be allowed to
continue this
medically necessary treatment to prevent or limit emotional lability,
undesired regression of
hormonally-induced physical effects and the sense of desperation that may
lead to depression,
anxiety and suicidality. Prisoners who are subject to rapid withdrawal of
cross-sex hormones are
particularly at risk for psychiatric symptoms and self-injurious behaviors.
Medical monitoring of
hormonal treatment as described in these Standards should also be provided.
Housing for
transgendered prisoners should take into account their transition status and
their personal safety.
VIII. Effects of Hormone Therapy in Adults
The maximum physical effects of hormones may not be evident until two years
of continuous
treatment. Heredity limits the tissue response to hormones and this cannot
be overcome by
increasing dosage. The degree of effects actually attained varies from
patient to patient.
Desired Effects of Hormones. Biologic males treated with estrogens can
realistically expect
treatment to result in: breast growth, some redistribution of body fat to
approximate a female
body habitus, decreased upper body strength, softening of skin, decrease in
body hair, slowing or
stopping the loss of scalp hair, decreased fertility and testicular size,
and less frequent, less firm
erections. Most of these changes are reversible, although breast enlargement
will not completely
reverse after discontinuation of treatment.
Biologic females treated with testosterone can expect the following
permanent changes: a
deepening of the voice, clitoral enlargement, mild breast atrophy, increased
facial and body hair
and male pattern baldness. Reversible changes include increased upper body
strength, weight
gain, increased social and sexual interest and arousability, and decreased
hip fat.
Potential Negative Medical Side Effects. Patients with medical problems or
otherwise at risk
for cardiovascular disease may be more likely to experience serious or fatal
consequences of
cross-sex hormonal treatments. For example, cigarette smoking, obesity,
advanced age, heart
disease, hypertension, clotting abnormalities, malignancy, and some
endocrine abnormalities
may increase side effects and risks for hormonal treatment. Therefore, some
patients may not be
able to tolerate cross-sex hormones. However, hormones can provide health
benefits as well as
risks. Risk-benefit ratios should be considered collaboratively by the
patient and prescribing
physician.
Side effects in biologic males treated with estrogens and progestins may
include increased
propensity to blood clotting (venous thrombosis with a risk of fatal
pulmonary embolism),
development of benign pituitary prolactinomas, infertility, weight gain,
emotional lability, liver
disease, gallstone formation, somnolence, hypertension, and diabetes
mellitus.
Side effects in biologic females treated with testosterone may include
infertility, acne, emotional
lability, increases in sexual desire, shift of lipid profiles to male
patterns which increase the risk
of cardiovascular disease, and the potential to develop benign and malignant
liver tumors and
hepatic dysfunction.
The Prescribing Physician's Responsibilities. Hormones are to be prescribed
by a physician,
and should not be administered without adequate psychological and medical
assessment before
and during treatment. Patients who do not understand the eligibility and
readiness requirements
and who are unaware of the SOC should be informed of them. This may be a
good indication for
a referral to a mental health professional experienced with gender identity
disorders.
The physician providing hormonal treatment and medical monitoring need not
be a specialist in
endocrinology, but should become well-versed in the relevant medical and
psychological aspects
of treating persons with gender identity disorders.
After a thorough medical history, physical examination, and laboratory
examination, the
physician should again review the likely effects and side effects of hormone
treatment, including
the potential for serious, life-threatening consequences. The patient must
have the capacity to
appreciate the risks and benefits of treatment, have his/her questions
answered, and agree to
medical monitoring of treatment. The medical record must contain a written
informed consent
document reflecting a discussion of the risks and benefits of hormone
therapy.
Physicians have a wide latitude in what hormone preparations they may
prescribe and what
routes of administration they may select for individual patients. Viable
options include oral,
injectable, and transdermal delivery systems. The use of transdermal
estrogen patches should be
considered for males over 40 years of age or those with clotting
abnormalities or a history of
venous thrombosis. Transdermal testosterone is useful in females who do not
want to take
injections. In the absence of any other medical, surgical, or psychiatric
conditions, basic medical
monitoring should include: serial physical examinations relevant to
treatment effects and side
effects, vital sign measurements before and during treatment, weight
measurements, and
laboratory assessment. Gender patients, whether on hormones or not, should
be screened for
pelvic malignancies as are other persons.
For those receiving estrogens, the minimum laboratory assessment should
consist of a
pretreatment free testosterone level, fasting glucose, liver function tests,
and complete blood
count with reassessment at 6 and 12 months and annually thereafter. A
pretreatment prolactin
level should be obtained and repeated at 1, 2, and 3 years. If
hyperprolactemia does not occur
during this time, no further measurements are necessary. Biologic males
undergoing estrogen
treatment should be monitored for breast cancer and encouraged to engage in
routine selfexamination.
As they age, they should be monitored for prostatic cancer.
For those receiving androgens, the minimum laboratory assessment should
consist of
pretreatment liver function tests and complete blood count with reassessment
at 6 months, 12
months, and yearly thereafter. Yearly palpation of the liver should be
considered. Females who
have undergone mastectomies and who have a family history of breast cancer
should be
monitored for this disease.
Physicians may provide their patients with a brief written statement
indicating that the person is
under medical supervision, which includes cross-sex hormone therapy. During
the early phases
of hormone treatment, the patient may be encouraged to carry this statement
at all times to help
prevent difficulties with the police and other authorities.
Reductions in Hormone Doses After Gonadectomy. Estrogen doses in post-orchiectomy
patients can often be reduced by 1/3 to ½ and still maintain feminization.
Reductions in
testosterone doses post-oophorectomy should be considered, taking into
account the risks of
osteoporosis. Lifelong maintenance treatment is usually required in all
gender patients.
The Misuse of Hormones. Some individuals obtain hormones without
prescription from friends,
family members, and pharmacies in other countries. Medically unmonitored
hormone use can
expose the person to greater medical risk. Persons taking medically
monitored hormones have
been known to take additional doses of illicitly obtained hormones without
their physician's
knowledge. Mental health professionals and prescribing physicians should
make an effort to
encourage compliance with recommended dosages, in order to limit morbidity.
It is ethical for
physicians to discontinue treatment of patients who do not comply with
prescribed treatment
regimens.
Other Potential Benefits of Hormones. Hormonal treatment, when medically
tolerated, should
precede any genital surgical interventions. Satisfaction with the hormone's
effects consolidates
the person's identity as a member of the preferred sex and gender and
further adds to the
conviction to proceed. Dissatisfaction with hormonal effects may signal
ambivalence about
proceeding to surgical interventions. In biologic males, hormones alone
often generate adequate
breast development, precluding the need for augmentation mammaplasty. Some
patients who
receive hormonal treatment will not desire genital or other surgical
interventions.
The Use of Antiandrogens and Sequential Therapy. Antiandrogens can be used
as adjunctive
treatments in biologic males receiving estrogens, though they are not always
necessary to
achieve feminization. In some patients, antiandrogens may more profoundly
suppress the
production of testosterone, enabling a lower dose of estrogen to be used
when adverse estrogen
side effects are anticipated.
Feminization does not require sequential therapy. Attempts to mimic the
menstrual cycle by
prescribing interrupted estrogen therapy or substituting progesterone for
estrogen during part of
the month are not necessary to achieve feminization.
Informed Consent. Hormonal treatment should be provided only to those who
are legally able
to provide informed consent. This includes persons who have been declared by
a court to be
emancipated minors and incarcerated persons who are considered competent to
participate in
their medical decisions. For adolescents, informed consent needs to include
the minor patient's
assent and the written informed consent of a parent or legal guardian.
Reproductive Options. Informed consent implies that the patient understands
that hormone
administration limits fertility and that the removal of sexual organs
prevents the capacity to
reproduce. Cases are known of persons who have received hormone therapy and
sex
reassignment surgery who later regretted their inability to parent
genetically related children. The
mental health professional recommending hormone therapy, and the physician
prescribing such
therapy, should discuss reproductive options with the patient prior to
starting hormone therapy.
Biologic males, especially those who have not already reproduced, should be
informed about
sperm preservation options, and encouraged to consider banking sperm prior
to hormone therapy.
Biologic females do not presently have readily available options for gamete
preservation, other
than cryopreservation of fertilized embryos. However, they should be
informed about
reproductive issues, including this option. As other options become
available, these should be
presented.
IX.
The Real-Life Experience
The act of fully adopting a new or evolving gender role or gender
presentation in everyday life is
known as the real-life experience. The real-life experience is essential to
the transition to the
gender role that is congruent with the patient’s gender identity. Since
changing one's gender
presentation has immediate profound personal and social consequences, the
decision to do so
should be preceded by an awareness of what the familial, vocational,
interpersonal, educational,
economic, and legal consequences are likely to be. Professionals have a
responsibility to discuss
these predictable consequences with their patients. Change of gender role
and presentation can
be an important factor in employment discrimination, divorce, marital
problems, and the
restriction or loss of visitation rights with children. These represent
external reality issues that
must be confronted for success in the new gender presentation. These
consequences may be quite
different from what the patient imagined prior to undertaking the real-life
experiences. However,
not all changes are negative.
Parameters of the Real-Life Experience. When clinicians assess the quality
of a person's reallife
experience in the desired gender, the following abilities are reviewed:
1. To maintain full or part-time employment;
2. To function as a student;
3. To function in community-based volunteer activity;
4. To undertake some combination of items 1-3;
5. To acquire a (legal) gender-identity-appropriate first name;
6. To provide documentation that persons other than the therapist know that
the patient
functions in the desired gender role.
Real-Life Experience versus Real-Life Test. Although professionals may
recommend living in
the desired gender, the decision as to when and how to begin the real-life
experience remains the
person's responsibility. Some begin the real-life experience and decide that
this often imagined
life direction is not in their best interest. Professionals sometimes
construe the real-life
experience as the real-life test of the ultimate diagnosis. If patients
prosper in the preferred
gender, they are confirmed as "transsexual," but if they decided against
continuing, they "must
not have been." This reasoning is a confusion of the forces that enable
successful adaptation with
the presence of a gender identity disorder. The real-life experience tests
the person's resolve, the
capacity to function in the preferred gender, and the adequacy of social,
economic, and
psychological supports. It assists both the patient and the mental health
professional in their
judgments about how to proceed. Diagnosis, although always open for
reconsideration, precedes
a recommendation for patients to embark on the real-life experience. When
the patient is
successful in the real-life experience, both the mental health professional
and the patient gain
confidence about undertaking further steps.
Removal of Beard and other Unwanted Hair for the Male to Female Patient.
Beard density
is not significantly slowed by cross-sex hormone administration. Facial hair
removal via
electrolysis is a generally safe, time-consuming process that often
facilitates the real-life
experience for biologic males. Side effects include discomfort during and
immediately after the
procedure and less frequently hypo-or hyper pigmentation, scarring, and
folliculitis. Formal
medical approval for hair removal is not necessary; electrolysis may be
begun whenever the
patient deems it prudent. It is usually recommended prior to commencing the
real-life
experience, because the beard must grow out to visible lengths to be
removed. Many patients
will require two years of regular treatments to effectively eradicate their
facial hair. Hair removal
by laser is a new alternative approach, but experience with it is limited.
X. Surgery
Sex Reassignment is Effective and Medically Indicated in Severe GID. In
persons diagnosed
with transsexualism or profound GID, sex reassignment surgery, along with
hormone therapy
and real-life experience, is a treatment that has proven to be effective.
Such a therapeutic
regimen, when prescribed or recommended by qualified practitioners, is
medically indicated and
medically necessary. Sex reassignment is not "experimental,"
"investigational," "elective,"
"cosmetic," or optional in any meaningful sense. It constitutes very
effective and appropriate
treatment for transsexualism or profound GID.
How to Deal with Ethical Questions Concerning Sex Reassignment Surgery. Many
persons,
including some medical professionals, object on ethical grounds to surgery
for GID. In ordinary
surgical practice, pathological tissues are removed in order to restore
disturbed functions, or
alterations are made to body features to improve the patient’s self image.
Among those who
object to sex reassignment surgery, these conditions are not thought to
present when surgery is
performed for persons with gender identity disorders. It is important that
professionals dealing
with patients with gender identity disorders feel comfortable about altering
anatomically normal
structures. In order to understand how surgery can alleviate the
psychological discomfort of
patients diagnosed with gender identity disorders, professionals need to
listen to these patients
discuss their life histories and dilemmas. The resistance against performing
surgery on the ethical
basis of "above all do no harm" should be respected, discussed, and met with
the opportunity to
learn from patients themselves about the psychological distress of having
profound gender
identity disorder.
It is unethical to deny availability or eligibility for sex reassignment
surgeries or hormone
therapy solely on the basis of blood seropositivity for blood-borne
infections such as HIV, or
hepatitis B or C, etc.
The Surgeon’s Relationship with the Physician Prescribing Hormones and the
Mental
Health Professional. The surgeon is not merely a technician hired to perform
a procedure. The
surgeon is part of the team of clinicians participating in a long-term
treatment process. The
patient often feels an immense positive regard for the surgeon, which
ideally will enable longterm
follow-up care. Because of his or her responsibility to the patient, the
surgeon must
understand the diagnosis that has led to the recommendation for genital
surgery. Surgeons should
have a chance to speak at length with their patients to satisfy themselves
that the patient is likely
to benefit from the procedures. Ideally, the surgeon should have a close
working relationship
with the other professionals who have been actively involved in the
patient’s psychological and
medical care. This is best accomplished by belonging to an interdisciplinary
team of
professionals who specialize in gender identity disorders. Such gender teams
do not exist
everywhere, however. At the very least, the surgeon needs to be assured that
the mental health
professional and physician prescribing hormones are reputable professionals
with specialized
experience with gender identity disorders. This is often reflected in the
quality of the
documentation letters. Since fictitious and falsified letters have
occasionally been presented,
surgeons should personally communicate with at least one of the mental
health professionals to
verify the authenticity of their letters.
Prior to performing any surgical procedures, the surgeon should have all
medical conditions
appropriately monitored and the effects of the hormonal treatment upon the
liver and other organ
systems investigated. This can be done alone or in conjunction with medical
colleagues. Since
pre-existing conditions may complicate genital reconstructive surgeries,
surgeons must also be
competent in urological diagnosis. The medical record should contain written
informed consent
for the particular surgery to be performed.
XI. Breast Surgery
Breast augmentation and removal are common operations, easily obtainable by
the general
public for a variety of indications. Reasons for these operations range from
cosmetic indications
to cancer. Although breast appearance is definitely important as a secondary
sex characteristic,
breast size or presence are not involved in the legal definitions of sex and
gender and are not
important for reproduction. The performance of breast operations should be
considered with the
same reservations as beginning hormonal therapy. Both produce relatively
irreversible changes
to the body.
The approach for male-to-female patients is different than for
female-to-male patients. For
female-to-male patients, a mastectomy procedure is usually the first surgery
performed for
success in gender presentation as a man; and for some patients it is the
only surgery undertaken.
When the amount of breast tissue removed requires skin removal, a scar will
result and the
patient should be so informed. Female-to-male patients may have surgery at
the same time they
begin hormones. For male-to-female patients, augmentation mammoplasty may be
performed if
the physician prescribing hormones and the surgeon have documented that
breast enlargement
after undergoing hormone treatment for 18 months is not sufficient for
comfort in the social
gender role.
Eligibility Criteria.
These minimum eligibility criteria for various genital
surgeries equally
apply to biologic males and females seeking genital surgery. They are:
1. Legal age of majority in the patient's nation;
2. Usually 12 months of continuous hormonal therapy for those without a
medical
contraindication (see below, "Can Surgery Be Performed Without Hormones and
the
Real-life Experience");
3. 12 months of successful continuous full time real-life experience.
Periods of returning to
the original gender may indicate ambivalence about proceeding and generally
should not
be used to fulfill this criterion;
4. If required by the mental health professional, regular responsible
participation in
psychotherapy throughout the real-life experience at a frequency determined
jointly by
the patient and the mental health professional. Psychotherapy per se is not
an absolute
eligibility criterion for surgery;
5. Demonstrable knowledge of the cost, required lengths of hospitalizations,
likely
complications, and post surgical rehabilitation requirements of various
surgical
approaches;
6. Awareness of different competent surgeons.
Readiness Criteria.
The readiness criteria include:
1. Demonstrable progress in consolidating one’s gender identity;
2. Demonstrable progress in dealing with work, family, and interpersonal
issues resulting in
a significantly better state of mental health; this implies satisfactory
control of problems
such as sociopathy, substance abuse, psychosis, suicidality, for instance).
Can Surgery Be Provided Without Hormones and the Real-life Experience?
Individuals
cannot receive genital surgery without meeting the eligibility criteria.
Genital surgery is a
treatment for a diagnosed gender identity disorder, and should undertaken
only after careful
evaluation. Genital surgery is not a right that must be granted upon
request. The SOC provide for
an individual approach for every patient; but this does not mean that the
general guidelines,
which specify treatment consisting of diagnostic evaluation, possible
psychotherapy, hormones,
and real-life experience, can be ignored. However, if a person has lived
convincingly as a
member of the preferred gender for a long period of time and is assessed to
be a psychologically
healthy after a requisite period of psychotherapy, there is no inherent
reason that he or she must
take hormones prior to genital surgery.
Conditions under which Surgery May Occur. Genital surgical treatments for
persons with a
diagnosis of gender identity disorder are not merely another set of elective
procedures. Typical
elective procedures only involve a private mutually consenting contract
between a patient and a
surgeon. Genital surgeries for individuals diagnosed as having GID are to be
undertaken only
after a comprehensive evaluation by a qualified mental health professional.
Genital surgery may
be performed once written documentation that a comprehensive evaluation has
occurred and that
the person has met the eligibility and readiness criteria. By following this
procedure, the mental
health professional, the surgeon and the patient share responsibility of the
decision to make
irreversible changes to the body.
Requirements for the Surgeon Performing Genital Reconstruction. The surgeon
should be a
urologist, gynecologist, plastic surgeon or general surgeon, and
Board-Certified as such by a
nationally known and reputable association. The surgeon should have
specialized competence in
genital reconstructive techniques as indicated by documented supervised
training with a more
experienced surgeon. Even experienced surgeons in this field must be willing
to have their
therapeutic skills reviewed by their peers. Surgeons should attend
professional meetings where
new techniques are presented.
Ideally, the surgeon should be knowledgeable about more than one of the
surgical techniques for
genital reconstruction so that he or she, in consultation with the patient,
will be able to choose
the ideal technique for the individual patient. When surgeons are skilled in
a single technique,
they should so inform their patients and refer those who do not want or are
unsuitable for this
procedure to another surgeon.
Genital Surgery for the Male-to-Female Patient. Genital surgical procedures
may include
orchiectomy, penectomy, vaginoplasty, clitoroplasty, and labiaplasty. These
procedures require
skilled surgery and postoperative care. Techniques include penile skin
inversion, pedicled
rectosigmoid transplant, or free skin graft to line the neovagina. Sexual
sensation is an important
objective in vaginoplasty, along with creation of a functional vagina and
acceptable cosmesis.
Other Surgery for the Male-to-Female Patient. Other surgeries that may be
performed to
assist feminization include reduction thyroid chondroplasty,
suction-assisted lipoplasty of the
waist, rhinoplasty, facial bone reduction, face-lift, and blepharoplasty.
These do not require
letters of recommendation from mental health professionals.
There are concerns about the safety and effectiveness of voice modification
surgery and more
follow-up research should be done prior to widespread use of this procedure.
In order to protect
their vocal cords, patients who elect this procedure should do so after all
other surgeries
requiring general anesthesia with intubation are completed.
Genital Surgery for the Female-to-Male Patient. Genital surgical procedures
may include
hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty,
scrotoplasty, urethroplasty,
placement of testicular prostheses, and phalloplasty. Current operative
techniques for
phalloplasty are varied. The choice of techniques may be
restricted by anatomical or surgical
considerations. If the objectives of phalloplasty are a neophallus of good
appearance, standing
micturition, sexual sensation, and/or coital ability, the patient should be
clearly informed that
there are several separate stages of surgery and frequent technical
difficulties which may require
additional operations. Even metoidioplasty, which in theory is a one-stage
procedure for
construction of a microphallus, often requires more than one surgery. The
plethora of techniques
for penis construction indicates that further technical development is
necessary.
Other Surgery for the Female-to-Male Patient. Other surgeries that may be
performed to
assist masculinization include liposuction to reduce fat in hips, thighs and
buttocks.
XIII. Post-Transition
Follow-up
Long-term postoperative follow-up is encouraged in that it is one of the
factors associated with a
good psychosocial outcome. Follow-up is important to the patient's
subsequent anatomic and
medical health and to the surgeon's knowledge about the benefits and
limitations of surgery.
Long-term follow-up with the surgeon is recommended in all patients to
ensure an optimal
surgical outcome. Surgeons who operate on patients who are coming from long
distances should
include personal follow-up in their care plan and attempt to ensure
affordable, local, long-term
aftercare in the patient's geographic region. Postoperative patients may
also sometimes exclude
themselves from follow-up with the physician prescribing hormones, not
recognizing that these
physicians are best able to prevent, diagnose and treat possible long term
medical conditions that
are unique to hormonally and surgically treated patients. Postoperative
patients should undergo
regular medical screening according to recommended guidelines for their age.
The need for
follow-up extends to the mental health professional, who having spent a
longer period of time
with the patient than any other professional, is in an excellent position to
assist in any postoperative
adjustment difficulties.
WPATH
the
World Professional Association for Transgender Health Ami B. Kaplan, LCSW
113 University Place New York, New York 10003 (212) 358-1884 email: info@amikaplan.net
